History of Radiosurgeryby Giovanni Rigoli and Laura Fariselli

Radiation delivery techniques of SRS and SRT/SBRT

The fundamental concepts include the following: [11, 76]

the delivery of a very high dose of radiation (in a single treatment for SRS or in a maximum of five fractions for SRT/SBRT),
the use of many beams with small diameter (from 4 to 15 mm.) highly focused on the lesion,
the limited target volume of the lesion,
a very heterogeneous dose distribution within the target,
the use of a steep dose gradient with minimal dose delivered to the surrounding structures,
the stereotactic localization of the target, that determine the exact coordinates, based on integrated imaging (Angiography, CT, MRI, PET/CT),
the system to immobilize and carefully position the patient and maintain the patient position during therapy,
the use of computerized dosimetry planning systems based on three-dimensional integrated imaging,
a highly accurate radiation delivery system with an image-guided radiation therapy (IGRT), preventing or accounting for organ motion (in SBRT) [11].

Main criteria followed in writing the history

SRS and SRT/SBRT are at the cutting edge of radiation therapy techniques; increasingly involving a complex interaction of software and hardware, imaging and delivery, and static and dynamic systems, with an ever-decreasing tolerance for error [35].

The operative process of SRS and SRT/SBRT involves the use of a stereotactic frame and a high-resolution imaging system, such as computed tomography or magnetic resonance imaging. The data gathered are transferred to a digitized-data processing system, which precisely calculates the target’s coordinates and the radiation doses needed to destroy the lesion by means of an extremely high-performing radiotherapy instrument.

In conclusion, Stereotactic radiosurgery could be defined as a synthesis of many disciplines interconnected with each other:

the anatomy and the physiology of the brain and the body,
the oncology for the cancer lesions,
the neurology for other pathologies,
the stereotactic neurosurgery,
the mechanics of advanced patient positioning (as the stereotactic frames or frameless techniques of imaging) and patient immobilization,
the radiotherapy made with different external sources (Cobalt, X-Photons, Charged particles, Ultrasounds),
the technologies of imaging: vascular and radiological equipment, computerized tomography, magnetic resonance, nuclear medicine and positron emission tomography and specific X-ray tracking equipment,
specific devices as multi-leaf collimators (MLCs), micro-MLCs, advanced control systems,
the medical physics of advanced treatment planning systems.

We report, in chronological order, all the important events, that represented an important discovery or an evolution of existing technologies in the disciplines above mentioned.

Thread of the history

The leitmotif of the whole history of radiosurgery can be highlighted in the continuous search for devices, methods and tools that decrease the invasiveness and toxicity of the treatments. This concept has been very well expressed in the words of Harvey Cushing: “I would like to see the day when somebody would be appointed surgeon somewhere who had no hands, for the operative part is the least of the work “. This common thread is found in all the interpreters and the events of this story.

The Timeline

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